Simulation in clinical design: Testing a building before it’s built

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How do you go about building a new medical facility that improves upon current workflow and safety but also anticipates technologies and care models yet to be developed?

It’s a daunting task, and one that demands collaboration among all stakeholders: clinical staff, patients/their families and building architects. A workgroup from Boston Children’s met with consultants from FKP architects to come up with a vision for a brand new clinical building set to open in 2022. As part of the pre-planning process, FKP proposed a bold idea: constructing life-size cardboard replicas of clinical areas for doctors, nurses and patient families to “test” with simulated scenarios.

“There are no disadvantages to this approach,” says Uma Ramanathan, AIA, lead architect on the project for Shepley Bulfinch, the architecture firm designing the new building. “If only everyone could use this level of detail!” Shepley Bulfinch joined the simulation project to observe and record data and insights.

“For architects, visualizing space comes easily,” Ramanathan adds. “Not so much for others.”

‘Cardboard City’

In July 2015, “Cardboard City” came to life across the street from the hospital. The project workgroup ultimately involved a wide spectrum of stakeholders, including the Boston Children’s Simulator Program, physicians, nurses, architects, administrators and parents.

Catherine Allan, MD, clinical director of the Simulator Program, directed the project through every stage: initial planning, running the simulations, debriefing, and data analysis. As a critical care cardiologist, Allan also offered her insights as an inpatient provider with the Heart Center, which will gain a significant amount of clinical space with the new building.

“The simulation component is what made this innovative,” explains Allan, “because architects and builders have been ‘mocking up’ spaces for clients to walk through for years.”

“What we’re doing,” she says, “is letting clinicians understand what it will be like to work in that space. You could miss things that are relevant to doing a job by just walking through.”

During the simulations, teams of clinical staff ran through the motions of various complicated scenarios in the designated “rooms” of the cardboard hospital. They simulated surgeries, catheterizations, placing patients on cardiopulmonary support and outpatient scenarios. Allan’s colleague Sarah de Ferranti, MD, director of the Preventive Cardiology Program, volunteered to share her thoughts from an outpatient provider’s perspective.

Lessons learned from simulated scenarios

“The simulation revealed a lot about patient and provider entry and exit, the flow of movement,” says Allan. Door placement turned out to be a key issue.

“[In the operating room], surgeons want the bypass on right side of the table, behind the lead surgeon,” she says. “But the way the doors were set up, it would have to be wheeled all around.” In the end, the doors were re-positioned diagonally opposite one another to optimize workflow, cleanliness and safety. One door connected the operating room to the clean equipment space, and the other led out to the hall.

“That made it hit home to me, that you need flexibility in your process to allow unforeseen learnings,” says Allan.

Doors played a large role in the outpatient simulation, too. The team experimented with having two doors to a patient room: one for patients and families to enter from the waiting area, and the other for providers to enter from a central, isolated workspace. But providers said they like interacting with patients in the hallways, and in reality, “the doctor entering from another room seemed a little theatrical,” says de Ferranti.

The second door was scratched.

20150713_CardboardCity-21In the outpatient arena, another important insight was that all of the “components” of a room— the computers, the patient beds, the tables— should be movable. In all areas, sink placement proved to be another important but oft overlooked factor.

“Safety and infection control are top priorities,” says Ramanathan, who is keenly aware of the extensive regulations instituted by the Massachusetts Department of Public Health. “The clinicians should be able to immediately wash their hands upon entering a room, before they touch a patient,” she says. “And at the same time, a parent wants to see the doctor washing her hands, so visibility from the back of the room is also key. Life-size mockups help you see where things fit.”

In addition, adds Ramanathan, the simulations can help everyone envision and plan for technologies that are rapidly advancing and may need to be incorporated into structural designs. For example, “If we know that a display wall is coming in the future, we can provide all the backend work that might be necessary to accommodate that tool. We have to all be ready to digitize everything.”

All about the patients

Overall, says de Ferranti, the simulations yielded important and unexpected feedback. “Parent feedback was very helpful,” she says. “And so were comments from nurses, who do things that the doctors may not be aware of.”

She says some teams have used the simulated set-up “ad hoc” in addition to the scheduled times, and the simple act of getting together to talk openly about the layout has been valuable.

Still, she notes that any conversation about advancing clinical care “is about how we take care of patients, not just the space in which we see them.”

Learn more about the Boston Children’s Simulator Program.

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